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General Information About Adult Primary Liver Cancer

Liver cancer includes two major types: hepatocellular carcinoma (HCC) and intrahepatic bile duct cancer. (Refer to the Cellular Classification of Adult Primary Liver Cancer section of this summary for additional, less-common variances; also refer to the PDQ summary on Bile Duct Cancer [Cholangiocarcinoma] Treatment for more information.)

Incidence and Mortality

Estimated new cases and deaths from liver and intrahepatic bile duct cancer in the United States in 2019:[1]

New cases: 42,030.

Deaths: 31,780.

HCC is relatively uncommon in the United States, although its incidence is rising, principally in relation to the spread of hepatitis C virus infection.[2] Worldwide, HCC is the sixth most prevalent cancer and the third leading cause of cancer-related deaths.[3]

Anatomy

Anatomy of the liver. The liver is in the upper abdomen near the stomach, intestines, gallbladder, and pancreas. The liver has a right lobe and a left lobe. Each lobe is divided into two sections (not shown).

Risk Factors

Increasing age is the most important risk factor for most cancers. Other risk factors for liver (hepatocellular) cancer include the following:

(Refer to the PDQ summary on Liver [Hepatocellular] Cancer Prevention for more information.)

Screening

(Refer to the PDQ summary on Liver [Hepatocellular] Cancer Screening for more information.)

Diagnostic Factors

For lesions that are smaller than 1 cm and are detected during screening in patients at high risk for HCC, further diagnostic evaluation is not required because most of these lesions will be cirrhotic lesions rather than HCC.[24][Level of evidence: 3iii] Close follow-up at 3-month intervals is a common surveillance strategy, using the same technique that first documented the presence of the lesions.

For patients with liver lesions larger than 1 cm who are at risk for HCC, a diagnosis can be considered. The tests required to diagnose HCC may include imaging, biopsy, or both.

Diagnostic imaging

In patients with cirrhosis, liver disease, or other risk factors for HCC, and with lesions greater than 1 cm, triple-phase, contrast-enhanced studies (dynamic computed tomography [CT] or magnetic resonance imaging [MRI]) can be used to establish a diagnosis of HCC.[25]

A triple-phase CT or MRI assesses the entire liver in distinct phases of perfusion. Following the controlled administration of intravenous contrast media, the arterial and venous phases of perfusion are imaged.

During the arterial phase of the study, HCC enhances more intensely than the surrounding liver because the arterial blood in the liver is diluted by venous blood that does not contain contrast, whereas the HCC contains only arterial blood. In the venous phase, the HCC enhances less than the surrounding liver (which is referred to as the venous washout of HCC), because the arterial blood flowing through the lesion no longer contains contrast; however, the portal blood in the liver now contains contrast.

The presence of arterial uptake followed by washout in a single dynamic study is highly specific (95%–100%) for HCC of 1 to 3 cm in diameter and virtually diagnostic of HCC.[26,27,28][Level of evidence: 3ii] In these cases, the diagnosis of HCC may be established without the need for a second imaging modality, even in the absence of a biopsy confirmation.[28,29,30][Level of evidence: 3ii]

However, if a first imaging modality, such as a contrast-enhanced CT or MRI, is not conclusive, sequential imaging with a different modality can improve sensitivity for HCC detection (from 33% to 41% for either CT or MRI to 76% for both studies when performed sequentially) without a decrease in specificity.[27]

If, despite the use of two imaging modalities, a lesion larger than 1 cm remains uncharacterized in a patient at high risk for HCC (i.e., with no or only one classic enhancement pattern), a liver biopsy can be considered.[28,29]

Liver biopsy

A liver biopsy may be performed when a diagnosis of HCC is not established by a dynamic imaging modality (three-phase CT or MRI) for liver lesions 1 cm or larger in high-risk patients.

Alpha-fetoprotein (AFP) levels

AFP is insufficiently sensitive or specific for use as a diagnostic assay. AFP can be elevated in intrahepatic cholangiocarcinoma and in some cases in which there are metastases from colon cancer. Finding a mass in the liver of a patient with an elevated AFP does not automatically indicate HCC. However, if the AFP level is high, it can be used to monitor for recurrence.

Prognosis

The natural course of early tumors is poorly known because most HCC patients are treated. However, older reports have described 3-year survival rates of 13% to 21% without any specific treatment.[31,32] At present, only 10% to 23% of patients with HCC may be surgical candidates for curative-intent treatment.[33,34] The 5-year overall survival (OS) rate for patients with early HCC who are undergoing liver transplant is 44% to 78%; and for patients undergoing a liver resection, the OS rate is 27% to 70%.[35]

Liver transplantation, surgical resection, and ablation offer high rates of complete responses and a potential for cure in patients with early HCC.[29]

The natural course of advanced-stage HCC is better known. Untreated patients with advanced disease usually survive less than 6 months.[36] The survival rate of untreated patients in 25 randomized clinical trials ranged from 10% to 72% at 1 year and 8% to 50% at 2 years.[37]

Unlike most patients with solid tumors, the prognosis of patients with HCC is affected by the tumor stage at presentation and by the underlying liver function. The following prognostic factors guide the selection of treatment:

Anatomic extension of the tumor (i.e., tumor size, number of lesions, presence of vascular invasion, and extrahepatic spread).

A new prognostic system for hepatocellular carcinoma: a retrospective study of 435 patients: the Cancer of the Liver Italian Program (CLIP) investigators. Hepatology 28 (3): 751-5, 1998.

Cellular Classification of Adult Primary Liver Cancer

Malignant primary tumors of the liver consist of two major cell types, which are hepatocellular (90% of cases) and cholangiocarcinoma.[1]

Histologic classification is as follows:

Hepatocellular carcinoma (HCC; liver cell carcinoma).

Fibrolamellar variant of HCC.

It is important to distinguish between the fibrolamellar variant of HCC and HCC itself because an increased proportion of patients with the fibrolamellar variant may be cured if the tumor can be resected. This variant is found more frequently in young women. It also generally exhibits a slower clinical course than the more common HCC.[2]

Cholangiocarcinoma (intrahepatic bile duct carcinoma).

Mixed hepatocellular cholangiocarcinoma.

Undifferentiated.

Hepatoblastoma. This occurs more often in children than in adults. (Refer to the PDQ summary on Childhood Liver Cancer Treatment for more information.)

Stage Information for Adult Primary Liver Cancer

Prognostic modeling in hepatocellular carcinoma (HCC) is complex because cirrhosis is involved in as many as 80% of the cases. Tumor features and the factors related to functional hepatic reserve must be considered. The key prognostic factors are only partially known and vary at different stages of the disease.

More than ten classifications are used throughout the world, but no system is accepted worldwide. New classifications have been proposed to overcome the difficulties of having several staging systems.

This summary discusses the following three staging systems:

Barcelona Clinic Liver Cancer (BCLC) Staging System.

Okuda Staging System.

American Joint Committee on Cancer (AJCC) Staging System.

Barcelona Clinic Liver Cancer (BCLC) Staging System

Currently, the BCLC staging classification is the most accepted staging system for HCC and is useful in the staging of early tumors. Evidence from an American cohort has shown that BCLC staging offers better prognostic stratification power than other staging systems.[1]

The BCLC staging system attempts to overcome the limitations of previous staging systems by including variables related to the following:[2]

Tumor stage.

Functional status of the liver.

Physical status.

Cancer-related symptoms.

Five stages (0 and A through D) are identified based on the variables mentioned above. The BCLC staging system links each HCC stage to appropriate treatment modalities as follows:

Patients with end-stage disease who have a very poor life expectancy are offered supportive care and palliation.

Okuda Staging System

The Okuda staging system has been extensively used in the past and includes variables related to tumor burden and liver function, such as bilirubin, albumin, and ascites. However, many significant prognostic tumor factors confirmed in both surgical and nonsurgical series (e.g., unifocal or multifocal, vascular invasion, portal venous thrombosis, or locoregional lymph node involvement) are not included.[3,4] As a result, Okuda staging is unable to stratify prognosis for early-stage cancers and mostly serves to recognize end-stage disease.

AJCC Staging System and Definitions of TNM

The TNM (tumor, node, metastasis) classification for staging, proposed by the AJCC, is not widely used for liver cancer. Clinical use of TNM staging is limited because liver function is not considered. It is also difficult to use this system to select treatment options because TNM staging relies on detailed histopathological examination available only after tumor excision. TNM may be useful in prognostic prediction after liver resection.[5]

T4 = Single tumor or multiple tumors of any size involving a major branch of the portal vein or hepatic vein, or tumor(s) with direct invasion of adjacent organs other than the gallbladder or with perforation of visceral peritoneum.

T4 = Single tumor or multiple tumors of any size involving a major branch of the portal vein or hepatic vein, or tumor(s) with direct invasion of adjacent organs other than the gallbladder or with perforation of visceral peritoneum.

N1 = Regional lymph node metastasis.

M0 = No distant metastasis.

IVB

Any T, Any N, M1

Any T = See descriptions above in this table, stage IVA, Any T, N1, M0.

Treatment Option Overview for Adult Primary Liver Cancer

There is no agreement on a single treatment strategy for patients with hepatocellular carcinoma (HCC). Selection of treatment is complex due to several factors, including:

Underlying liver function.

Extent and location of the tumor.

General condition of the patient.

Several treatments for HCC are associated with long-term survival, including surgical resection, liver transplantation, and ablation. There are no large, robust, randomized studies that compare treatments considered effective for early-stage disease, nor are there studies comparing these treatments with best supportive care. Often, patients with HCC are evaluated by a multidisciplinary team including hepatologists, radiologists, interventional radiologists, radiation oncologists, transplant surgeons, surgical oncologists, pathologists, and medical oncologists.

Best survivals are achieved when the HCC can be removed either by surgical resection or liver transplantation. Surgical resection is usually performed in patients with localized HCC and enough functional hepatic reserve.

For patients with decompensated cirrhosis and a solitary lesion (<5 cm) or early multifocal disease (≤3 lesions, ≤3 cm in diameter), the best option is liver transplantation,[1] but the limited availability of liver donors restricts the use of this approach.

Among noncurative treatments for HCC, transarterial chemoembolization and sorafenib have been shown to improve survival.[2,3,4]

For treatment, HCC can be divided into the following two broad categories:

Tumors for which potentially curative treatments are available (BCLC stages 0, A, and B).

Tumors for which curative options are not available (BCLC stages C and D).

Stages 0, A, and B Adult Primary Liver Cancer Treatment

Localized hepatocellular carcinomas (HCCs) that present as a solitary mass in a portion of the liver or as a limited number of tumors (≤3 lesions, ≤3 cm in diameter) without major vascular invasion constitute approximately 30% of the HCC cases.

There are three potentially curative therapies that are acceptable treatment options for small, single-lesion HCC in patients with well-preserved liver function.

Resection and transplantation achieve the best outcomes in well-selected candidates and are usually considered to be the first option for curative intent.

Surgical Resection

Surgery is the mainstay of HCC treatment.

Preoperative assessment includes three-phase helical computed tomography, magnetic resonance imaging, or both to determine the presence of an extension of a tumor across interlobar planes and potential involvement of the hepatic hilus, hepatic veins, and inferior vena cava. Tumors can be resected only if enough liver parenchyma can be spared with adequate vascular and biliary inflow and outflow. Patients with well-compensated cirrhosis can generally tolerate resection of up to 50% of their liver parenchyma.

Surgical resection can be considered for patients who meet the following criteria:

A solitary mass.

Good performance status.

Normal or minimally abnormal liver function tests.

No evidence of portal hypertension.

No evidence of cirrhosis beyond Child-Pugh class A.

After considering the location and number of tumors, and the hepatic function of the patient, only 5% to 10% of patients with liver cancer will prove to have localized disease amenable to resection.[1,2,3,4,5]

The principles of surgical resection involve obtaining a clear margin around the tumor, which may require any of the following:

Segmental resection.

Hormone-lymphatic lobectomy.

Extended lobectomy.

The 5-year overall survival (OS) rate after curative resection ranges between 27% and 70% and depends on tumor stage and underlying liver function.[1,2,3,4,5]

In patients with limited multifocal disease, hepatic resection is controversial.

Liver Transplantation

Liver transplantation is a potentially curative therapy for HCC and has the benefit of treating the underlying cirrhosis, but the scarcity of organ donors limits the availability of this treatment modality.[1]

According to the Milan criteria, patients with a single HCC lesion smaller than 5 cm, or 2 to 3 lesions smaller than 3 cm are eligible for liver transplantation. Expansion of the accepted transplantation criteria for HCC is not supported by consistent data. Liver transplantation is considered if resection is precluded because of multiple, small, tumor lesions (≤3 lesions, each <3 cm), or if the liver function is impaired (Child-Pugh class B and class C). In patients who meet the criteria, transplantation is associated with a 5-year OS rate of approximately 70%.[6][Level of evidence: 3iiiA]

Ablation

When tumor excision, either by transplant or resection, is not feasible or advisable, ablation may be used if the tumor can be accessed percutaneously or, if necessary, through minimally invasive or open surgery. Ablation may be particularly useful for patients with early-stage HCC that is centrally located in the liver and cannot be surgically removed without excessive sacrifice of functional parenchyma.

With ablation, a margin of normal liver around the tumor can be considered. Ablation is relatively contraindicated for lesions near bile ducts, the diaphragm, or other intra-abdominal organs that might be injured during the procedure. Furthermore, when tumors are located adjacent to major vessels, the blood flow in the vessels may keep thermal ablation techniques, such as RFA, from reaching optimal temperatures. This is known as the heat-sink effect, which may preclude complete tumor necrosis.

RFA achieves best results in patients with tumors smaller than 3 cm. In this subpopulation of patients, 5-year OS rates may be as high as 59%, and the recurrence-free survival rates may not differ significantly from treatment with hepatic resection.[7,8] Local control success progressively diminishes as the tumor size increases beyond 3 cm.

PEI obtains good results in patients with Child-Pugh class A cirrhosis and a single tumor smaller than 3 cm in diameter. In those cases, the 5-year OS rate is expected to be as high as 40% to 59%.[9,10][Level of evidence: 3iiiD]

In the few randomized, controlled trials that included patients with Child-Pugh class A cirrhosis, RFA proved superior to PEI in rates of complete response and local recurrences; some of those studies have also shown improved OS with RFA. Furthermore, RFA requires fewer treatment sessions than PEI to achieve comparable outcomes.[11,12,13,14]

Of note, RFA may have higher complication rates than PEI,[12] but both techniques are associated with lower complication rates than excision procedures. RFA is a well-established technique in the treatment of HCC.

Use our advanced clinical trial search to find NCI-supported cancer clinical trials that are now enrolling patients. The search can be narrowed by location of the trial, type of treatment, name of the drug, and other criteria. General information about clinical trials is also available.

TAE is the most widely used primary treatment for hepatocellular carcinoma (HCC) not amenable to curative treatment by excision or ablation. Most of the blood supply to the normal liver parenchyma comes from the portal vein, whereas blood flow to the tumor comes mainly from the hepatic artery. Furthermore, HCC tumors are generally hypervascular compared with the surrounding normal parenchyma. The obstruction of the arterial branch(es) feeding the tumor may reduce the blood flow to the tumor and result in tumor ischemia and necrosis.

Embolization agents, such as microspheres and particles, may also be administered along with concentrated doses of chemotherapeutic agents (generally doxorubicin or cisplatin) mixed with lipiodol or other emulsifying agents during chemoembolization, arterial chemoembolization (usually via percutaneous access), and TACE. TAE-TACE is considered for patients with HCC who are not amenable to surgery or percutaneous ablation in the absence of extrahepatic disease.

In patients with cirrhosis, any interference with arterial blood supply may be associated with significant morbidity and is relatively contraindicated in the presence of portal hypertension, portal vein thrombosis, or clinical jaundice. In patients with liver decompensation, TAE-TACE could increase the risk of liver failure.

A number of randomized, controlled trials have compared TAE and TACE with supportive care.[1] Those trials have been heterogeneous in terms of patient baseline demographics and treatment. The survival advantage of TAE-TACE over supportive care has been demonstrated by two trials.[2,3] No standardized approach for TAE has been determined (e.g., embolizing agent, chemotherapy agent and dose, and treatment schedule). However, a meta-analysis has shown that TAE-TACE improves survival more than supportive treatment.[1]

The use of drug-eluting beads (DEB) for TACE has the potential of reducing systemic side effects of chemotherapy and may increase objective tumor response.[4,5,6,7] Only one study has suggested that DEB-TACE may offer an advantage in overall survival (OS).[8]

Targeted Therapy (Multikinase Inhibitors)

Two oral multikinase inhibitors, sorafenib and lenvatinib, are U.S. Food and Drug Administration (FDA)-approved for first-line treatment of patients with advanced HCC with well-compensated liver function who are not amenable to local therapies. Regorafenib is approved for second-line treatment of patients with advanced HCC who have progressed on sorafenib.

There are limited data on treatment options for patients with decompensated liver function.

First-line sorafenib

Evidence (sorafenib):

The SHARP trial (NCT00105443) randomly assigned 602 patients with advanced HCC to receive either sorafenib 400 mg twice daily or a placebo. All but 20 of the patients had a Child-Pugh class A liver disease score; 13% were women.[9]

A subsequent, similar trial conducted in 23 centers in China, South Korea, and Taiwan included 226 patients (97% with Child-Pugh class A liver function) with twice as many patients randomly assigned to sorafenib as to placebo.[10]

The median OS rate was 6.5 months for the sorafenib group versus 4.2 months for the placebo group (HR, 0.68; 95% CI, 0.50–0.93; P = .014).

Adverse events attributed to sorafenib in both of these trials included hand-foot skin reaction and diarrhea.[9,10]

Studies are also ongoing to evaluate the role of sorafenib after TACE, with chemotherapy, or in the presence of more-advanced liver disease.

First-line lenvatinib

Evidence (lenvatinib):

In an international, open-label, phase III, noninferiority trial (E7080-G000-304 [NCT01761266]) that included patients from 20 countries in Asia, Europe, and North America, 954 patients with advanced HCC and Child-Pugh A disease were randomly assigned in a 1:1 ratio to receive lenvatinib (12 mg qd for body weight >60 kg or 8 mg for body weight <60 kg) or sorafenib (400 mg bid in 28-day cycles).[11] Patients with more than a 50% liver involvement and portal vein invasion were excluded.

Median OS was 13.6 months, which reached noninferiority, for patients who received lenvatinib and 12.3 months for patients who received sorafenib (HR, 0.92; 95% CI, 0.79–1.06).[11][Level of evidence: 1iiDiii]

Median progression-free survival was 7.4 months for patients who received lenvatinib and 3.7 months for patients who received sorafenib (HR, 0.66; 95% CI, 0.57–0.77).

Treatment-related adverse events were similar between the lenvatinib arm and the sorafenib arm.

In the lenvatinib arm, the most common side effects were hypertension (any grade, 42%), diarrhea (39%), decreased appetite (34%), and decreased weight (31%), with 11 treatment-related deaths (hepatic failure, hemorrhage, and respiratory failure).

In the sorafenib arm, the most common side effects were palmar-plantar erythrodysesthesia (any grade, 52%), diarrhea (46%), hypertension (30%), and decreased appetite (27%), with four treatment-related deaths (hemorrhage, stroke, respiratory failure, and sudden death).

Second-line regorafenib

Evidence (regorafenib):

In an international, double-blind, placebo-controlled, phase III trial (RESORCE [NCT01774344]) that included patients from 21 countries in Asia, Europe, North America, South America, and Australia, 573 patients with advanced HCC and Child-Pugh A disease who had tolerated sorafenib, but had disease progression, were randomly assigned in a 2:1 ratio to receive regorafenib (160 mg/day on days 1–21 of a 28-day cycle) versus placebo.[12]

Median OS was 10.6 months for patients who received regorafenib and 7.8 months for patients who received a placebo (HR, 0.63; 95% CI, 0.50–0.79).[12][Level of evidence: 1iA]

The most common grade 3–4 regorafenib-related side effects were hypertension (15%), hand-foot syndrome (13%), fatigue (9%), and diarrhea (3%).

Second-line Immunotherapy

Checkpoint inhibitors, particularly programmed death 1 (PD-1) inhibitors are actively being evaluated in the management of advanced HCC.

The total overall objective response rate in the dose-expansion phase was 20% (95% CI, 15–26) with three complete responses. Results were similar in untreated, refractory, and HBV/HCV-infected patients. [13][Level of evidence: 2Div]

On the basis of these data, the FDA has granted accelerated approval for nivolumab for patients with advanced HCC previously treated with sorafenib.

Radiation Therapy

The role of radiation therapy for HCC has traditionally been limited by the low dose tolerance of the liver to radiation. However, recent technological developments in radiation therapy, including breathing-motion management and image-guided radiation therapy, have allowed for more precise and targeted radiation therapy delivery to the liver. Because of these advances, conformal liver irradiation has become feasible in the treatment of focal HCC.

Several phase II studies have suggested a benefit of radiation therapy in local control and OS compared with historical controls for patients with locally advanced HCC unsuitable for standard locoregional therapies.[14,15][Level of evidence: 3iiDiii]

Systemic Chemotherapy

There is no evidence supporting a survival benefit for patients with advanced HCC receiving systemic cytotoxic chemotherapy when compared with no treatment or best supportive care.

The efficacy of other targeted therapy agents (e.g., sunitinib and brivanib), other checkpoint inhibitors (e.g. pembrolizumab), and combinations of immunotherapy and targeted therapy is currently being investigated.

Current Clinical Trials

Use our advanced clinical trial search to find NCI-supported cancer clinical trials that are now enrolling patients. The search can be narrowed by location of the trial, type of treatment, name of the drug, and other criteria. General information about clinical trials is also available.

Recurrent Adult Primary Cancer Treatment

Intrahepatic recurrence is the most common pattern of failure after curative treatment.[1] Intrahepatic recurrence of hepatocellular carcinoma (HCC) may be the result of either intrahepatic metastasis or metachronous de novo tumor. Theoretically, intrahepatic metastasis may be associated with less favorable outcomes because it is most likely the result of concurrent hematogenous metastases. However, in clinical practice, the two causes of recurrence cannot be differentiated from each other.

Regarding primary HCC, the treatment strategy for recurrent intrahepatic HCC is determined by the function of the liver and the macroscopic tumor features (e.g., number of lesions, site of recurrence, and invasion of major vessels). Using the same selection criteria that are used for primary HCC, either curative (i.e., salvage liver transplant, surgical resection, and ablation) or palliative treatments (e.g., TACE and sorafenib) can be offered for recurrent HCC.

Evidence (salvage liver transplant, resection, and ablation):

In a retrospective study of 183 patients with intrahepatic recurrence, only 87 of the patients could be treated with curative intent (transplantation, resection, and ablation).[2][Level of evidence: 1A]

The 5-year tumor-free survival rate was 57.9% for liver transplantation, 49.3% for resection, and 10.6% for radiofrequency ablation. Subgroup analysis showed that transplantation and resection led to comparable survival and that both treatments led to significantly better outcomes than did ablation (P < .001); however, selection bias was a major pitfall of this retrospective study.

Other than the use of ablation for secondary treatment, risk factors for shorter disease-free survival were identified as alpha-fetoprotein blood levels above 400 ng/mL and recurrence within 1 year of treatment (47.5% vs. 6.7% at 5 years, P < .001).

Other studies have also suggested that most of the recurrences that appear early during follow-up are caused by tumor dissemination and have a more aggressive biological pattern than primary tumors.[3,4]

Clinical trials are appropriate and can be offered to patients with recurrent HCC whenever possible.

Current Clinical Trials

Use our advanced clinical trial search to find NCI-supported cancer clinical trials that are now enrolling patients. The search can be narrowed by location of the trial, type of treatment, name of the drug, and other criteria. General information about clinical trials is also available.

Changes to This Summary (10 / 03 / 2019)

The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.

General Information About Adult Primary Liver Cancer

The Risk Factors subsection was extensively revised.

This summary is written and maintained by the PDQ Adult Treatment Editorial Board, which is editorially independent of NCI. The summary reflects an independent review of the literature and does not represent a policy statement of NCI or NIH. More information about summary policies and the role of the PDQ Editorial Boards in maintaining the PDQ summaries can be found on the About This PDQ Summary and PDQ® - NCI's Comprehensive Cancer Database pages.

About This PDQ Summary

Purpose of This Summary

This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about the treatment of adult primary liver cancer. It is intended as a resource to inform and assist clinicians who care for cancer patients. It does not provide formal guidelines or recommendations for making health care decisions.

Reviewers and Updates

This summary is reviewed regularly and updated as necessary by the PDQ Adult Treatment Editorial Board, which is editorially independent of the National Cancer Institute (NCI). The summary reflects an independent review of the literature and does not represent a policy statement of NCI or the National Institutes of Health (NIH).

Board members review recently published articles each month to determine whether an article should:

be discussed at a meeting,

be cited with text, or

replace or update an existing article that is already cited.

Changes to the summaries are made through a consensus process in which Board members evaluate the strength of the evidence in the published articles and determine how the article should be included in the summary.

The lead reviewers for Adult Primary Liver Cancer Treatment are:

Russell S. Berman, MD (New York University School of Medicine)

Valerie Lee, MD (Johns Hopkins University)

Franco M. Muggia, MD (New York University Medical Center)

Any comments or questions about the summary content should be submitted to Cancer.gov through the NCI website's Email Us. Do not contact the individual Board Members with questions or comments about the summaries. Board members will not respond to individual inquiries.

Levels of Evidence

Some of the reference citations in this summary are accompanied by a level-of-evidence designation. These designations are intended to help readers assess the strength of the evidence supporting the use of specific interventions or approaches. The PDQ Adult Treatment Editorial Board uses a formal evidence ranking system in developing its level-of-evidence designations.

Permission to Use This Summary

PDQ is a registered trademark. Although the content of PDQ documents can be used freely as text, it cannot be identified as an NCI PDQ cancer information summary unless it is presented in its entirety and is regularly updated. However, an author would be permitted to write a sentence such as "NCI's PDQ cancer information summary about breast cancer prevention states the risks succinctly: [include excerpt from the summary]."

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